Medical Benefits and Copayments

Blue Cross and Blue Shield of Texas offers health care benefits and access to care to help you stay well. BCBSTX covers medically necessary care that we OK ahead of time such as:

  • Visits to PCPs, specialists or other providers
  • Preventive care
  • Emergency services
  • Hospital services
  • And more

Get a full list of your covered benefits in Part 19 of your CHIP Member Handbook.

CHIP Copayments

If you get CHIP Perinatal benefits, you do not have cost-sharing obligations, including enrollment fees and copayments (copays). CHIP Members who are Native American or Alaskan Native also do not have cost-sharing obligations, including enrollment fees and copays.

How much are copays and when do they apply? 
Your member's card shows if you have a copay. If you are a Native American or an Alaskan Native, then please call BCBSTX to have this copay amount corrected. You will not have to pay copays for the following:

  • Primary Care Provider (PCP) visits for well-baby and well-child services
  • Preventive services
  • Pregnancy-related assistance

The following chart shows your copay for different services, based on income guidelines.
 

Copays and Cost-Sharing
SERVICE At or below 151% FPL* Above 151% up to and including 186% FPL* Above 186% up to and including 201% FPL*
Enrollment Fee $0 $35 $50
Office visit $5 $20 $25
Non-emergency ER (per visit) $5 $75 $75
Emergency room (ER) $0 $0 $0
Facility Copay, Inpatient (per admission) $35 $75 $125
Generic drug $0 $10 $10
Brand drug $5 $35 $35
Cost-sharing cap (limit) 5% of family's income** 5% of family's income** 5% of family's income**

*The federal poverty level (FPL) refers to income guidelines established annually by the federal government.

** Per 12-month term of coverage.


If you have received a bill or paid out of pocket for a covered service, call the Customer Advocate Department. They can review your covered benefits with you and help you submit a claim if needed.

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